A Dedicated SARS-CoV-2 Testing Center for Public Service Agency Personnel: Implementation, Results, and Impact on Human Resources.

Objective: A global pandemic due to an emerging infectious disease requires efficient use of resources to ensure continued operation of essential services. To mitigate risk to these services and the population served, there needs to be a rapid identification of infected personnel via screening and testing.Methods: This retrospective study used prospectively collected data from a dedicated SARS-CoV-2 testing center for fire, police, and paramedic personnel in Toronto, Canada to determine the incidence of seropositive personnel and their immediate household, and estimate the days off work saved by timely access to testing and results.Results: In the consecutive 12-month study period, 10624 tests were carried out. Of 7951 personnel tested, 282 (3.55%) were positive, with positivity rates ranging from 2.52% for paramedics, 4.01% for police, and 4.25% for fire personnel. Household members tested positive in 173 of 2592 cases (6.67%), ranging from 5.22% for fire, 6.34% for paramedic, and 7.04% for police households. The median time to obtain test results was 1 day, with 90% available within 2 days. Implementation of the Center is estimated to have saved the Services 7669 person-days off work.Conclusion: A dedicated SARS-CoV-2 testing center for essential personnel can improve access to diagnostic testing and turnaround time for results, and provide a positive impact on human resource availability during a pandemic.

Evaluation of a primary care paramedic STEMI bypass guideline.

OBJECTIVE: Limited evidence supports primary care paramedic (PCP) direct transport of ST-segment elevation myocardial infarction (STEMI) patients for percutaneous coronary intervention (PCI). The goal of this study was to evaluate an urban-based PCP STEMI bypass guideline. METHODS: We reviewed consecutive Toronto Paramedic Services call reports between April 7, 2015, and May 31, 2016, regarding STEMI patients identified by PCPs. The primary outcome was patient assignment (stable versus unstable) according to guideline criteria. Secondary outcomes were the proportion of PCP-transported patients who had an indication for an advanced care intervention (ACI) or who received an ACI when PCPs rendezvoused with an advanced care paramedic (ACP). Lastly, we reviewed prehospital outcomes of cardiac arrest patients and calculated the difference in transport intervals between direct PCP bypass and a PCI-centre and predicted transport interval to the closest emergency department (ED). RESULTS: Of 361 patients, 232 were PCP transports and 129 were ACP-rendezvous transports. There was a significant difference in the distribution of stable and unstable patients between PCPs and ACPs (p<0.001). For PCP patients, 21/232 (9.1%) had indications for an ACI, whereas 34/129 (26.4%) ACP patients received an ACI. Eleven patients experienced cardiac arrest; 10 were successfully resuscitated (5 of these by PCPs). The median difference between direct PCP bypass and a PCI-centre versus transport to the closest ED was 5.53 minutes (IQR=6.71). CONCLUSIONS: We found a significant difference in the distribution of stable and unstable patients and fewer patients with indications for an ACI in PCP patients. This PCP STEMI bypass guideline appears feasible.

Paramedic-Initiated Home Care Referrals and Use of Home Care and Emergency Medical Services.

OBJECTIVE: We examined the association between paramedic-initiated home care referrals and utilization of home care, 9-1-1, and Emergency Department (ED) services. METHODS: This was a retrospective cohort study of individuals who received a paramedic-initiated home care referral after a 9-1-1 call between January 1, 2011 and December 31, 2012 in Toronto, Ontario, Canada. Home care, 9-1-1, and ED utilization were compared in the 6 months before and after home care referral. Nonparametric longitudinal regression was performed to assess changes in hours of home care service use and zero-inflated Poisson regression was performed to assess changes in the number of 9-1-1 calls and ambulance transports to ED. RESULTS: During the 24-month study period, 2,382 individuals received a paramedic-initiated home care referral. After excluding individuals who died, were hospitalized, or were admitted to a nursing home, the final study cohort was 1,851. The proportion of the study population receiving home care services increased from 18.2% to 42.5% after referral, representing 450 additional people receiving services. In longitudinal regression analysis, there was an increase of 17.4 hours in total services per person in the six months after referral (95% CI: 1.7-33.1, p = 0.03). The mean number of 9-1-1 calls per person was 1.44 (SD 9.58) before home care referral and 1.20 (SD 7.04) after home care referral in the overall study cohort. This represented a 10% reduction in 9-1-1 calls (95% CI: 7-13%, p < 0.001) in Poisson regression analysis. The mean number of ambulance transports to ED per person was 0.91 (SD 8.90) before home care referral and 0.79 (SD 6.27) after home care referral, representing a 7% reduction (95% CI: 3-11%, p < 0.001) in Poisson regression analysis. When only the participants with complete paramedic and home care records were included in the analysis, the reductions in 9-1-1 calls and ambulance transports to ED were attenuated but remained statistically significant. CONCLUSIONS: Paramedic-initiated home care referrals in Toronto were associated with improved access to and use of home care services and may have been associated with reduced 9-1-1 calls and ambulance transports to ED.

Assessment of the safety and effectiveness of emergency department STEMI bypass by defibrillation-only emergency medical technicians/primary care paramedics.

INTRODUCTION: The American Heart Association (AHA) suggests emergency medical service (EMS) providers transporting ST-segment elevation myocardial infarction (STEMI) patients to a percutaneous coronary intervention (PCI) center require advanced life support (ALS) skills. OBJECTIVES: To evaluate the potential safety and time savings effectiveness of defibrillation-only emergency medical technician/primary care paramedic (EMT-D/PCP) EMS transport to a PCI center in a system where only emergency medical technician-paramedics/advanced care paramedics (EMT-Ps/ACPs) are authorized to bypass non-PCI hospitals. METHODS: We reviewed 89 consecutive patients meeting STEMI criteria transported by EMT-Ds/PCPs per protocol by one of three paths: 1) closest non-PCI center emergency department (ED) with secondary transfer by EMT-Ps/ACPs to a PCI lab, 2) rendezvous with EMT-Ps/ACPs and diversion to a PCI lab, and 3) PCI center ED if it was closest. Actual transport times to the PCI center ED were compared to predicted transport times determined by mapping software had EMT-Ds/PCPs followed a direct path. Lastly, we recorded predefined clinically important events and advanced care interventions. RESULTS: Twenty-seven, 51, and 11 patients followed paths 1, 2, and 3 respectively. Median transport times for path 1 were 6 (IQR 5) minutes to reach the nearest non-PCI center ED and 66 (IQR 45) minutes to the PCI center ED compared to a median predicted 13 (IQR 7) minutes to a PCI center ED had EMT-Ds/PCPs followed a direct path. Median transport time for path 2 was 12 (IQR 8) minutes compared to a median predicted time of 11 (IQR 6) minutes had no EMT-P/ACP rendezvous occurred. Median transport time for path 3 was 7 minutes (IQR 5). Three patients experienced prehospital cardiac arrest; 1 required dopamine, and 4 others received a saline bolus for hypotension. CONCLUSIONS: Substantial time savings may occur if EMT-Ds/PCPs bypass non-PCI center EDs with only a small predicted increase (about 7 minutes) in the transport time to the PCI center ED. EMT-P/ACP rendezvous does not appear to substantially increase transport time. Given the relatively low occurrence of clinically important events, our findings suggest that EMT-D/PCP bypass to a PCI center ED may be safe and effective for selected STEMI patients.